Moral Side of Medicine
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cians to“ meet patients where they are.” 4 Physicians often feel pressured to have all the answers. Especially in the care of the dying, there may not be a good or certain answer, but physicians can guide patients and families through the uncertainty and establish mutually agreeable goals that are achievable. For example, learning and practicing the REMAP tool( Reframe why the status quo isn’ t working, Expect emotion & empathize, Map the future, Align with patient’ s values, Plan medical treatments that match patient values) provides a framework to fall back on during tense meetings where emotions are high. 5
Helpful Practices for Addressing Moral Challenges
Nothing is more important than recognizing personal limitations and engaging other professionals, but clinicians can also cultivate their own practices to bring their best selves to the ethical decision-making process. The authors of this article have found the following especially helpful:
1. Seek first to understand and build trust
Pause, listen, seek more information, remember that there is always more to the story, allow time for the process to evolve and don’ t jump to conclusions or premature solutions.
2. Focus on process, not outcome
Trust in a shared decision-making process, make clear medical recommendations based on agreed-on goals of care, but avoid focusing too intensely on a particular action or outcome. A conversation that explores exactly why a patient believes CPR would be effective may be more constructive than one focused only on why the physician believes it wouldn’ t.
3. Acknowledge uncertainty and consider multiple options
In a medical crisis, things can change quickly and outcomes are often uncertain. Consider a wide range of scenarios, actions and outcomes. Avoid a binary, all-or-none mindset. There are often reasonable middle-of-the-road options such as continuing but not escalating critical care interventions for a time-limited therapeutic trial.
4. Assume good intentions
Unless proven otherwise, assume that everyone involved wants to do the right thing for the patient even if they disagree about what that is. Respect their concerns and look for common ground, striving to stay positive and seek mutual understanding.
5. Use language thoughtfully
Use plain language, avoid medical jargon and adapt communication to the family’ s needs. Notice how they talk and mirror their style when appropriate. If they call the ventilator a“ breathing machine,” they may be more likely to feel heard and understood if the physician calls it that too. The use of“ Wish, Worry and Wonder” statements can be helpful for maintaining hope while allowing for the possibility of undesirable outcomes. 6
The social worker discovered a living will that was signed by the patient three years ago which stated that, if he were terminally ill or permanently unconscious and unable to give directions, he would authorize the withholding or withdrawal of life-prolonging treatment. 7 He did not designate a surrogate health care decision-maker. Under Kentucky law, since he was widowed, that responsibility was delegated to the majority of his five adult children. 8 The intensivist was concerned that the current family-directed treatment plan did not align with the patient’ s expressed wishes. The palliative care team recommended consulting the hospital ethics committee to address the discrepancy.
The Value of Interdisciplinary Palliative Care and Ethics Teams
When high-quality palliative care teams are involved, they ensure both expertise in communication and the presence of interdisciplinary professionals whose observations and assessments of the patient and family enhance overall care. In the absence of a high-quality palliative care team, the value of chaplains and mental health professionals cannot be overstated: a hospital chaplain or licensed clinical social worker in an oncology clinic can balance the physician’ s tendency toward over-medicalization. They are trained to recognize grief and emotion, not only in patients and families, but also their own colleagues. 9
While a high-quality palliative care team often prevents the escalation of emotionally charged situations, an ethics committee composed of professionals from a variety of disciplines and backgrounds is essential in addressing the complex ethical problems that frequently arise in healthcare. Evidence for the benefits of an ethics committee includes user satisfaction with ethics consultation, the perception of strengthened decisions on patient management and improvement in the quality of patient care. 10 An additional benefit includes supporting physicians in their treatment intentions and in learning how to have productive and ethically sensitive conversations.
When presented with the living will, three of the children who were previously mostly silent recalled conversations they’ d had with him when he executed it and expressed support for honoring its provisions. At a family meeting including the intensivist, palliative care team and ethics consultant, a consensus was reached to continue critical care for a limited three-day trial to observe for signs of neurological improvement while allowing the family time to organize a bedside prayer meeting. If no meaningful improvement ensued, the goals of care would then shift to
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